Journal of Substance Abuse Treatment 60 (2016) 110118

Contents lists available at ScienceDirect

Journal of Substance Abuse Treatment

Implementing Effective Substance Abuse Treatments in General Medical

Settings: Mapping the Research Terrain
Lori J. Ducharme, Ph.D. a,, Redonna K. Chandler, Ph.D. b, Alex H.S. Harris, Ph.D. c
a
National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD
b
National Institute on Drug Abuse, Bethesda, MD
c
VA Palo Alto Health Care System, Menlo Park, CA

a r t i c l e i n f o a b s t r a c t

Article history: The National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA), and
Received 1 March 2015 Veterans Health Administration (VHA) share an interest in promoting high quality, rigorous health services
Received in revised form 22 June 2015 research to improve the availability and utilization of evidence-based treatment for substance use disorders
Accepted 22 June 2015
(SUD). Recent and continuing changes in the healthcare policy and funding environments prioritize the integra-
tion of evidence-based substance abuse treatments into primary care and general medical settings. This area is a
Keywords:
Integrated care
prime candidate for implementation research. Recent and ongoing implementation projects funded by these
Implementation science agencies are reviewed. Research in ve areas is highlighted: screening and brief intervention for risky drinking;
Alcohol screening and brief intervention for tobacco use; uptake of FDA-approved addiction pharmacotherapies; safe opi-
Substance use disorders oid prescribing; and disease management. Gaps in the portfolios, and priorities for future research, are described.
Evidence-based practices Published by Elsevier Inc.
Primary care

1. Introduction overseeing portfolios of implementation research within three organi-

Decades of investment have yielded effective behavioral, psychoso-
cial, and pharmacological interventions to address substance use disor-
ders (SUD) and sub-diagnostic but hazardous substance use. Despite
this strong evidence, relatively few effective treatments and practices
have been widely adopted or faithfully implemented within general
medical settings. The quality of treatment for people with tobacco,
drug, and alcohol use disorders can be improved by integrating existing
evidence-based approaches into clinical settings in which high-risk
populations are engaged in routine medical care.
The integration of SUD treatment into general medical settings is a
topical area especially suited to implementation research. Not only is
there a need to develop and test novel service delivery models that
may achieve these goals, but there is a parallel need for research to de-
velop effective implementation strategies through which evidence-
based practices (EBPs) and service delivery models can be spread and
sustained. This paper attempts to identify persistent gaps in implemen-
tation research in the area of integrated service delivery and suggests
priority areas for implementation research needed to better integrate
SUD treatment into general medical settings. These observations are
offered from the perspective of program directors charged with
Corresponding author at: National Institute on Alcohol Abuse and Alcoholism, 5635
Fishers Lane, Rm 2045, Bethesda, MD, USA, 20892-9304. Tel.: +1 301 443 1206.
E-mail address: Lori.Ducharme@nih.gov (L.J. Ducharme).
zations that have worked to set priorities and stimulate addiction-
related implementation research: the National Institute on Alcohol
Abuse and Alcoholism (NIAAA), the National Institute on Drug Abuse
(NIDA), and the Veterans Health Administration (VHA) Substance Use
Disorder Quality Enhancement Research Initiative (SUD QUERI). The
purpose of this article is to take stock of where we have been, identify
well-trodden ground, and suggest new routes that NIH- and VA-
funded research might take to arrive at greater service integration for
SUD treatment.
An oft-cited statistic is that it takes 17 years for 14% of clinical discov-
ery to make its way into routine practice (Balas & Boren, 2000). While
some treatments prove infeasible for everyday clinical application,
there are also numerous practices that stall due to ineffective dissemi-
nation or a lack of proven implementation strategies. These leaks in
the translation pipeline are perhaps nowhere more noticeable than in
hospital-based detection and treatment of substance use disorders. In
the US, hospitalized patients with alcohol use disorders receive only a
fraction of the recommended care for their condition (McGlynn et al.,
2003), while SUDs play a prominent role in costly readmissions and
overutilization of hospital services among Medicaid patients (AHRQ,
2014; Neighbors et al., 2013). At the same time, many persons with
SUDs are unable or unwilling to seek treatment in specialty programs,
but routinely encounter other components of the healthcare system
(primary care visits, emergency departments, pharmacies). Thus, effec-
tively identifying and addressing SUDs in general medical settings could
help engage these patients, lower healthcare expenditures, and make a

http://dx.doi.org/10.1016/j.jsat.2015.06.020
0740-5472/Published by Elsevier Inc.
 L.J. Ducharme et al. / Journal of Substance Abuse Treatment 60 (2016) 110118
signicant public health impact. This requires that we identify those
treatments that might feasibly be delivered outside of specialty addic-
tion treatment programs, and that we develop effective implementation
strategies to help bridge this gap in service delivery.
Implementation science explicitly develops and tests interventions
(strategies) intended to affect the adoption and sustainment of
evidence-based practices and treatments in real world clinical settings.
For decades the funding and treatment for SUD has been separated from
that for other health conditions, making integration especially challeng-
ing (Manderscheid & Kathol, 2014). For the purpose of this article, we
dene general medical settings to include obstetric, pediatric, and ado-
lescent medicine; primary care practices including family practice and
internal medicine; medical services provided through Federally Quali-
ed Health Centers; Veterans Affairs Medical Centers and clinics; as
well as settings providing de facto primary care for patients who may
not otherwise receive it, whether for acute episodes (e.g., emergency
departments, trauma centers, urgent care clinics) or for chronic disease
management (e.g., HIV clinics). Importantly, these settings do not in-
clude specialty addiction treatment or mental health settings.
In recent years, and largely within the context of the Affordable Care
Act, Federal agencies across the US Department of Health and Human
Services have increasingly been supporting research to understand the
process, cost, and outcomes associated with integrating behavioral
health, including SUD treatment, into general medical care. For exam-
ple, the Agency for Healthcare Research and Quality (AHRQ) funds re-
search assessing the effectiveness of services delivered in integrated
care settings, including the impact of behavioral health on primary
care and health outcomes. Their Academy for Integrating Behavioral
Health and Primary Care (www.integrationacademy.ahrq.gov) serves
as a resource for ongoing review and synthesis of the results of research
on care integration being conducted across government and the private
sector (e.g., AHRQ, 2014). The Center for Integrated Health Solutions
(www.integration.samhsa.gov), a joint endeavor of the Substance
Abuse and Mental Health Services Administration (SAMHSA) and the
Health Resources and Services Administration (HRSA), promotes the
delivery of integrated primary care and behavioral health services
through demonstration projects and a public repository of information
on health homes, with a particular focus on safety-net providers. Mean-
while, the Centers for Medicare and Medicaid Services (CMS) has
funded two rounds of Healthcare Innovations Awards to develop and
test novel payment and service delivery models; these include projects
to transform traditional primary care practices into medical homes, and
accelerate innovation in service delivery (www.innovation.cms.gov).
VHAs Health Services Research and Development (HSR&D) and
QUERI programs have for many years funded research to develop and
evaluate integrated care models and their implementation (e.g., VHA,
2015a). And the National Institutes of Health (NIH) contribute to this
endeavor via support of health services research and implementation
science. Indeed, there are concerted efforts across government to pro-
mote the implementation of integrated service delivery; in this context,
NIH and VHA have been at the forefront in supporting hypothesis-
driven research in the pursuit of generalizable knowledge about effec-
tive and scalable implementation strategies to achieve these ends.
Within the current policy and nancing context, the US healthcare
infrastructure continues to evolve, and examples of innovative and suc-
cessful service integration models have begun to emerge. There is in-
creasingly a need to subject these candidate models to broader
testing, and to develop and deploy systematic implementation strate-
gies to take effective service delivery models to scale and sustain
them. Implementation science holds the promise for developing effec-
tive scale-up strategies that can leverage facilitators and overcome bar-
riers inherent in the complex contextual environments in which
services are delivered. Health services and implementation research
funded by the NIH and VHA has begun to provide scaffolding for effec-
tive scale-up of integrated care models to address the substance use dis-
order treatment needs of patients in general medical care settings.
111
1.1. Research on SUD service implementation and integration at NIH
The National Institutes of Health comprises 27 Institutes and
Centers, generally organized by focal disease or condition. Funding for
extramural grants is accomplished principally through investigator-
initiated applications; these applications are solicited via Funding Op-
portunity Announcements (FOAs), through which NIH program staff
describe needs for research in specic topic areas. In 2005, eight of the
27 Institutes including NIAAA and NIDA jointly issued the rst
multi-institute FOA on Dissemination and Implementation (D&I) Re-
search in Health. As is common when nurturing a new subeld, applica-
tions were initially assigned special receipt dates during alternating
review cycles, and were assigned to ad hoc peer review committees
(special emphasis panels) that evaluated only D&I applications. Inter-
est in this area has since grown to the point that as of 2014, a total of 14
Institutes and Centers were participating in the FOA, and the ow of ap-
plications was sufcient to justify a standing Center for Scientic Review
study section, convening every review cycle. Summaries of research
supported under this FOA have been previously published (Glasgow
et al., 2012; Neta et al., 2015; Tinkle, Kimball, Haozous, Shuster, &
Meize-Grochowski, 2013).
A 2012 report by the National Advisory Council on Drug Abuse
reviewed the NIDA implementation research portfolio to date and
made recommendations for future research and programmatic activi-
ties (NIDA, 2012). To promote implementation research on topics relat-
ed to alcohol and drug treatment services, NIAAA and NIDA have
incorporated D&I topics into their respective health services research
program announcements. The two institutes also share a joint R34 an-
nouncement to fund pilot testing of organizational and systems inter-
ventions to support implementation trials.
Implementation research in the area of service integration has been
a prominent focus of several recent FOAs. In particular, in 2012, NIDA re-
leased a Request for Applications (RFA) on the integration of drug abuse
prevention and treatment in primary care settings which yielded 7
funded grants. Other major initiatives to support service integration
have included release of the NIDAMed suite of tools to support physi-
cians identication of problem drug use, along with resources to ad-
dress safe opioid prescribing for primary care patients with chronic
pain (NIDA, 2015); NIAAAs release of clinicians guides to support the
screening and identication of patients with problematic alcohol use
in primary care (NIAAA, 2007, 2010, 2011); and ongoing efforts to pro-
mote the implementation of evidence-based screening and brief inter-
vention protocols to address tobacco use and risky drinking in general
medical settings.
1.2. Research on SUD service implementation and integration at VHA
VHAs Health Services Research and Development (HSR&D) service
funds investigator-initiated research on diverse aspects of service deliv-
ery for hazardous substance use and SUD, including but not limited to
quality measurement, comparative effectiveness, variation in access
and quality, and developing and testing models of behavioral healthcare
integration in diverse settings. Although the landscape of implementa-
tion research within VHA is undergoing a rapid realignment, from
1998 until 2015, implementation research has largely been supported
via the Quality Enhancement Research Initiative (QUERI). Historically,
QUERI has been structured around mostly disease-focused Centers, in-
cluding the Substance Use Disorder QUERI (SUD QUERI). The QUERI
Centers have set national strategic priorities for implementation re-
search in their focus areas, and have served a mentoring and consulta-
tive function to investigators developing implementation science
proposals to be submitted to a centralized peer-review process. The
Centers also directly support small implementation science projects.
The mission of the SUD QUERI is to improve the detection and treat-
ment of Veterans with SUD and hazardous substance use. The main ac-
tivities are to develop and evaluate strategies to implement evidence-
112 L.J. Ducharme et al. / Journal of Substance Abuse Treatment 60 (2016) 110118
based treatments, as well as strategies to de-implement ineffective
practices. The Center strives to 1) produce knowledge and products
that are used by operational partners to improve the quality and cost-
effectiveness of care for SUD patients; and 2) contribute to the accumu-
lation of knowledge about implementation contexts, strategies, costs,
and outcomes.
From 2012 to 2015, SUD QUERI investigators successfully competed
for ve Service Directed Projects (roughly equivalent to NIH R01s) and
over 20 smaller (~$100 k) Rapid Response Projects. Many of these pro-
jects focused on developing and testing strategies to implement models
of integrated care, such as screening and brief interventions for risky
drinking in primary care (described below); testing several unique
strategies (e.g., academic detailing, patient activation) for increasing
pharmacotherapy for alcohol use disorder across diverse clinical set-
tings; integration of HIV and HCV screening and treatment in SUD pro-
grams; and developing models of care to address substance use disorder
in infectious disease clinics.
Recently, SUD QUERI established updated priorities for addiction-
related implementation research in consultation with operational and
policy partners and outside implementation and addiction experts
through a method that weighed several factors including strength of ev-
idence, expected effect sizes, current quality gaps, organizational bar-
riers and facilitators, and other factors. Five of the six highest priority
areas involve coordination with clinical settings outside of addiction
programs (e.g., pharmacotherapy for alcohol use disorder) if not explicit
integration within them (e.g., screening and brief intervention for risky
drinking in primary care).
Conducting and facilitating implementation research within a large
integrated health care system comes with opportunities and challenges.
On the positive side, the existence of centralized policies and goals
make assembling a team of operational partners, clinical managers, and
researchers around the development and evaluation of implementation
solutions perhaps easier than it might be otherwise. On the challenging
side, a model of research that is tightly linked with implementing policy
and solving the problems of operational partners depends on the exis-
tence of cooperative and research-friendly partners and scientically
sound policy. It is not unusual for implementation scientists to be encour-
aged to develop and evaluate implementation strategies for practices that
have a poor evidence base, just because they have been reied in policy or
otherwise are subject to political or organizational enthusiasm. SUD
QUERI has worked hard to stay clear of these situations, but it is always
a tension. Also, tension can exist between the goal of developing concrete
solutions to specic problems versus the production of generalizable im-
plementation science knowledge. This tension sometimes impacts which
targets are chosen as well as design and methodological choices.
As of this writing, VHA is currently undergoing the most extensive re-
organization in a generation and the QUERI program is being substantially
revised. The existing mostly disease-focused QUERI centers, including SUD
QUERI, will stop operations in Sept 2015. The new QUERI will support
roughly 12 programs that will each consists of a cross-cutting impact
goal, three to ve implementation/quality improvement projects, and an
implementation science core tasked with coordinating and synthesizing
activities between projects and programs to maximize learning. Although
the SUD QUERI will not exist, most of the priorities established in its stra-
tegic plan have been integrated into several of the new program pro-
posals. Given that QUERI will no longer review investigator-initiated
implementation science projects, the HSR&D service will now consider
these proposals. A new HSR&D RFA that appears particularly relevant for
implementation science proposals is the Targeted Solicitation for Health
Services Research on Provider Behavior - A Learning Health Care System
Initiative. (http://www.hsrd.research.va.gov/funding/RFA-list.cfm).
2. Implementation of integrated care: domains and strategies
We reviewed all funded extramural grants (at NIAAA/NIDA) and
SUD QUERI projects (at VHA) between 2008-2014. Because NIH tobacco
treatment applications may be assigned either to NIDA or to the Nation-
al Cancer Institute (NCI), and consistent with the aims of the functional
integration of addiction research at NIH (see http://addictionresearch.
nih.gov), we also reviewed all grants funded by NCI that were specical-
ly related to the implementation of smoking cessation services in gener-
al medical care settings. Based on this review, we identied 5 domains
in which NIH and VHA have supported or prioritized implementation
science to address the integration of drug and alcohol treatment in
general medical settings. For each domain, we briey describe the
evidence-based clinical practices or service delivery models that are
ready to be implemented; provide examples of some of the implemen-
tation strategies being tested; and identify remaining research gaps. Our
objective is to provide a broad overview of the current research portfo-
lio in the area of implementation and integration. We provide citations
to publicly-accessible documents whenever possible. 1 However, be-
cause research studies may not yet have published their ndings, formal
citations are not always available.
Perhaps the most important components of these projects are the
implementation strategies that are being tested. In D&I research, the im-
plementation strategy is the active intervention; it is analogous to the
patient-level clinical intervention tested in a treatment development
study. Researchers are testing the effectiveness of a particular method
(implementation strategy) to change a particular process (service
delivery) that should result in a particular implementation outcome (in-
tegration of treatment services), which in turn should lead to improve-
ments in service quality and clinical outcomes (Proctor et al., 2009). As
with clinical interventions, implementation strategies may involve a
single activity or a bundle of activities (Powell, McMillen, Proctor,
et al., 2012). They may engage multiple levels of a medical practice
e.g., organizational structure, technology infrastructure, management/
leadership, clinicians, patients either simultaneously or sequentially.
While there are a limited number of EBPs for SUD that are ready for
implementation in general medical settings, there is potentially a much
broader array of implementation strategies that can be tested, and re-
search to date has tended to focus only on a limited set. At this point,
we can say that implementation as usual (whether by passive dissem-
ination, by typical classroom-style training of individual staff, or by pol-
icy directive in the absence of other supports) is unlikely to achieve
desired results when compared to active, facilitative, and multifaceted
strategies. Comparative effectiveness studies that test different imple-
mentation strategies or combinations of strategies are needed to move
the eld forward, particularly when examining service integration.
Well-specied and carefully tested implementation strategies tell us
how integration can be achieved, and allow for replication and scalabil-
ity (Proctor, Powell, & McMillen, 2013). Particularly in an era of health
reform, SUD treatment service integration may benet by borrowing ef-
fective models of integration from other areas of health care, and com-
paring different models to determine which strategies most effectively
achieve integration, in which settings, at what cost.
2.1. Practices to be implemented
Consistent across all funded projects in our portfolios is that the
practices being implemented must be evidence-based. Scientic review
panels as well as program staff pay careful attention to the strength and
quality of the evidence base, to avoid premature scale-up of therapies
that are unproven. When proposing implementation projects, re-
searchers should review the scientic literature, with an emphasis on
the results of well-designed randomized controlled trials in which
change in substance use is a primary outcome. FDA approval of medica-
tions is usually a signal of readiness for implementation; behavioral
(counseling) therapies are less easily declared ready for implementa-
tion, but high-quality meta-analyses including clinical trials conducted
1
Limited information about every awarded NIH extramural research grant is available
in a searchable public-access database at http://report.nih.gov.
 L.J. Ducharme et al. / Journal of Substance Abuse Treatment 60 (2016) 110118
by researchers other than the treatment developer are a key marker.
While there are a broad array of practices that are listed on any of a
number of registries of evidence-based practices, those registries can
vary widely in their criteria for inclusion and their process of evaluating
research results (Burkhardt, Schroter, Magura, Means, & Coryn, 2015;
Means, Magura, Burkhardt, Schroter, & Coryn, 2015); in some cases
therapies are listed in the absence of any supportive data from random-
ized trials. Thus being listed on a registry or having a set of manuals
and training curricula is not necessarily, in itself, a sufcient indicator
of readiness for scale-up. Nor is the popularity of a counseling technique
or clinical approach a sufcient substitute for evidence; indeed, a unique
challenge is posed for both research and practice when a service deliv-
ery model is incentivized or even mandated despite a lack of evidence
for its effectiveness (e.g., SBIRT for drug abuse (Roy-Byrne et al., 2014;
Saitz et al., 2014)). Because our funded portfolios represent an invest-
ment of public dollars, they necessarily reect a conservative reading
of the scientic research base.
In the context of integration into general medical settings, a further
consideration is the likely t between the substance abuse treatment
practice and the context into which it is earmarked for implementation
(Damschroder et al., 2009). For example, prescription medications are
highly compatible (Rogers, 2003) with most primary care practice set-
tings, and are likely to gain traction for implementation relatively quick-
ly once known barriers (e.g., familiarity, cost) are addressed. On the
other hand, complex, multifaceted behavioral interventions are difcult
to implement with delity even in specialty addiction programs; this
problem is further magnied on a general hospital unit, where they
are incompatible with the skills and workow of the staff who would
bear responsibility for delivery. Accommodations to these constraints
are reected in our research portfolios, which examine a small number
of clinical practices that have a clear evidence base to support
implementation, and are good candidates for integration into non-
specialty settings.
2.1.1. Screening and brief intervention for risky drinking
Based on accumulated evidence from randomized controlled trials,
summarized in a recent systematic review (Jonas et al., 2012), the US
Preventive Services Task Force (USPSTF) recommends that clinicians
screen adults for alcohol misuse, and that they provide brief behavioral
counseling to those who screen positive for risky or hazardous drinking.
Because of the USPSTFs assignment of a B grade to screening and brief
intervention (SBI) indicating a conclusion of moderate net benets
the Affordable Care Act requires that its delivery be included as a cov-
ered preventive services in health exchange plans. Importantly, the
combination of a solid evidence-base and access to insurance reim-
bursement paves the way for the development and testing of strategies
to implement SBI broadly in primary care settings.
A large number of what we might call pre-implementation studies
have been undertaken in this area, with many researchers focusing on
methods or technologies to optimize screening protocols to t into the
routine workow of busy clinical practice settings. For example, pro-
jects have tested the feasibility of embedding screening questions into
medical records; using clinical reminders and note templates for the
major components of brief intervention; or testing the effectiveness of
brief interventions delivered via computer rather than by clinician. By
and large, these studies have not been testing implementation strate-
gies to achieve the integration of those technologies, but this will be an
important next step for research, as we know that even the most effec-
tive technologies are not self-spreading.
In our funded grant portfolios to date, projects testing the integra-
tion of SBI into general medical settings have focused on two main
themes: testing staff-level vs. organizational-level implementation sup-
ports, and testing a generalist vs specialist model of SBI delivery. For the
most part, these projects are based within primary care settings, al-
though funded research has recently expanded to include hospital inpa-
tient units, trauma centers, and HIV clinics.
113
The rst group of studies tests bundled implementation interven-
tions with staff and/or organizational-level targets for change. Typically,
staff-level implementation interventions consist of training and
coaching to promote effective delivery of brief motivational interven-
tions. These may be coupled or contrasted with organizational-level im-
plementation strategies, such as the development and implementation
of quality measures, designed to enhance the local implementation cli-
mate, engage leadership in identifying and overcoming existing bar-
riers, and increase the likelihood of long-term sustainment. Where
there are local or national clinical practice mandates that are consistent
with implementation, these can be powerful levers for change. For ex-
ample, one recent study capitalized on a mandate from the American
College of Surgeons that Level 1 trauma centers in the U.S. must screen in-
jured patients for alcohol use disorders and intervene appropriately with
those who screen positive. This mandate provided a ready-made man-
date only control condition against which a more facilitative multi-
level implementation strategy could be tested (Zatzick et al., 2014).
Studies testing generalist vs. specialist protocols attempt to address
the concern that physicians have limited time to allocate to any one pa-
tient, and that SBI may not t within the routine workow of a physician
or practice. Likewise, primary care physicians may lack the skill or inter-
est to deliver brief interventions to address risky alcohol use by their pa-
tients. Several ongoing studies are testing an alternative service delivery
model, namely, the use of behavioral health specialists to deliver brief
interventions to patients who screen positive for hazardous drinking.
The general design compares a traditional model in which the physician
is trained and tasked with incorporating SBI into the patient visit, versus
an alternative model in which the patient meets with a designated be-
havioral health specialist prior to concluding their appointment (see,
e.g., Mertens, Sterling, Weisner, & Pating, 2013).
In some studies, the specialist is a staff member of a chemical depen-
dency treatment unit operated by or near the primary care practice, and
the scope of their intervention includes a referral to treatment, facilitat-
ing the patients contact with the specialty care program. While this in-
tervention requires a change to the existing workow of a practice
setting, it is likely to minimize the additional workload of any given
physician. A variation of this model is a current study testing the use
of a clinical liaison service (NIH Reporter, 2015a), through which a phy-
sician on a hospital inpatient unit can order a brief motivational inter-
view for a patient determined to need one. Because the clinical liaison
service is part of the everyday hospital environment and is commonly
used by physicians for other types of consults, and because the liaisons
assume responsibility for delivering the most complex part of the inter-
vention, a service delivery model that leverages this existing infrastruc-
ture should facilitate its uptake and sustainability.
VHAs experience with implementation of alcohol SBI suggests the
potential for sustained impacts on routine clinical practice. In part due
to foundational work done by QUERI investigators to develop training
materials (http://www.queri.research.va.gov/tools/alcohol-misuse/);
research linking alcohol screening scores to medical outcomes; and
the development and implementation of quality measures and clinical
reminders and note templates, annual screening of VHA patients with
the AUDIT-C is near universal (~ 90%) and rates of documented BI
among patients who screen positive are high and increasing (~ 80%)
(Bradley, DeBenedetti, et al., 2007; Bradley, Williams, et al., 2007;
Lapham, Achtmeyer, et al., 2012; Lapham, Hawkins, et al., 2012;
Williams, Achtmeyer, et al., 2010; Williams, Peytremann-Bridevaux,
et al., 2010; Williams et al., 2011, 2014). However, recent work has
found that the quality of documented SBI is often poor and the associa-
tion of SBI with outcomes might be weaker in real world practice com-
pared to results reported in efcacy studies (Williams et al., 2014). This
voltage drop is not uncommon for EBPs being delivered under real-
world conditions (Chambers, Glasgow, & Stange, 2013). Other research
has found possible unintended consequences of a quality measure for BI
(Bradley et al., 2013). In sum, SUD QUERIs experience suggests that fu-
ture implementation efforts and research are needed not only to
114 L.J. Ducharme et al. / Journal of Substance Abuse Treatment 60 (2016) 110118
implement these practices, but to attend to the quality of SBI beyond
merely motivating its documentation, and to continue to monitor effec-
tiveness and unintended consequences of these services as delivered.
2.1.2. Screening, brief intervention, and treatment for tobacco use
The USPSTF recommends that clinicians ask all adults including
pregnant women about tobacco use and provide tobacco cessation in-
terventions for those who use tobacco products. Their A grade for this
recommendation not only signals the high impact of this clinical prac-
tice, but also includes it among the list of covered preventive practices
under the Affordable Care Act. Moreover, a Public Health Service clinical
practice guideline on Treating Tobacco Use and Dependence (Fiore, Jan,
Baker, et al., 2008) provides detailed, easy-to-follow guidance for clini-
cians on screening and intervening with patients, including information
about quitlines, brief counseling, and nicotine replacement therapies.
This accumulation of evidence and resources provides the backdrop
for a robust portfolio of implementation studies to integrate the guide-
lines into a variety of medical practice settings.
Given the universal scope of the USPSTF recommendation, and the
broad applicability of the PHS guidelines, it is not surprising that funded
research in this domain seeks to implement tobacco SBI across a wide va-
riety of health care settings beyond primary care practices, including stu-
dent health clinics; pharmacies; rural hospitals; emergency departments;
county-run free clinics; and dental ofces. Across these settings, imple-
mentation strategies emphasize three common themes: leveraging tech-
nology to support guideline adherence; training; and promoting the use
of existing resources to facilitate service integration and sustainability.
Most NIH projects seeking to integrate tobacco treatment into gen-
eral medical settings have a technology component at the heart of their
implementation strategy. Recently, the creation and use of patient reg-
istries has become a common tool to help clinicians record and track
identied tobacco users and monitor the delivery of appropriate ser-
vices (e.g., via pharmacy records). In other studies, screening questions
or clinical alerts are embedded in the patients medical record, such that
physicians can be prompted to complete the 5 As (ask, advise, assess,
assist, arrange), deliver a brief intervention, prescribe a nicotine re-
placement therapy, or otherwise address tobacco use during the ofce
visit. Another strategy involves integrating the 5 As into the patient
check-in process, collecting responses directly from patients on a tablet
computer used in the clinic waiting area, and transmitting the informa-
tion to the medical record so that it can be accessed by the physician
during the visit. Each of these studies takes advantage of an information
technology infrastructure that already exists in primary care settings,
minimizing the need for additional resources, and increasing the likeli-
hood of long-term sustainability beyond the research project.
Conventional training and academic detailing are common imple-
mentation strategies to increase provider attention to tobacco use and
appropriate interventions. Given known limitations of training alone
as an implementation strategy, studies often embed some form of feed-
back and/or performance incentive to promote delivery of smoking ces-
sation services. Some studies are testing one or both of these training
strategies against a comparison condition in which only printed mate-
rials (posters and brochures) are distributed (e.g., Zillich et al., 2013);
these allow for comparison of informational campaigns that target phy-
sicians directly, versus a more direct-to-consumer dissemination strate-
gy. Outcomes at two levels can thus be considered clinician delivery of
tobacco interventions, and patients use of pharmacy products and
quitline services. Across the portfolio of integration research, this is
one of the few domains in which direct-to-patient dissemination of in-
formation about available services (medications, quitlines) is a common
implementation strategy.
Tobacco is one public health issue for which there are a variety of free
or subsidized resources available for patients in the community, and im-
plementation studies including these in their protocols both conserve
research resources and increase the likelihood of sustainability. For ex-
ample, patients can be directed to state-run tobacco quitlines, while
clinics can often obtain a supply of printed materials to make available
in public areas.
As in other areas of substance abuse integration research, re-
searchers are testing implementation strategies with targets at multiple
levels patients, clinicians, and organizations. Multi-level interventions
appear to be important for implementation success. Two recent studies
demonstrated success in improving organizational-level readiness to
change, and improving clinic workow and data systems to support to-
bacco interventions; however, these projects were less successful at in-
creasing clinician delivery of motivational interventions (McNamara
et al., 2015) or otherwise achieving near-term changes in patient receipt
of services (Foley et al., 2012).
VHA HSR&D and QUERI have funded research examining strategies
to implement screening, brief intervention, and treatment for tobacco
use disorder in diverse settings (e.g., primary care, medical inpatient
units), for patients with specic co-morbidities (e.g., stroke), and
employing a diversity of modalities (e.g., face-to-face, web-based, tele-
health), and varied interventionists (e.g. nurses, peer specialists) (see
descriptions at VHA, 2015b). Many of these projects involved effective-
ness studies of new treatment care delivery models (e.g., telephone
counseling by peers), and pre-implementation studies of barriers and
facilitators to implementing promising models more broadly. Less
common are studies that evaluate specic implementation and
sustainment strategies. Perhaps ironically, the implementation of
screening, brief intervention, and treatment for tobacco use disorder
in VHA has been more successful in general medical settings compared
to addiction treatment programs, where the prevalence of tobacco use
disorder is very high. SUD QUERI has historically focused on addressing
this gap. For example, a current study is studying a blended facilitation
model to implement tobacco use disorder treatment in VA residential
SUD programs.
2.1.3. Uptake of FDA-approved pharmacotherapies
Until recently, much of the NIH implementation research portfolio in
the area of pharmacotherapies has consisted of observational studies
that characterize clinician attitudes toward medications for alcohol
and drug dependence; document the extent of adoption by clinicians
and programs; and describe structural barriers to broader use. This seg-
ment of the portfolio has overwhelmingly focused on the specialty care
system, and while there are few implementation studies in this arena,
they too have tended to focus on improving the rates of medication
adoption in specialty treatment settings. In stark contrast to the tobacco
treatment implementation portfolio, research on integrating addiction
medications into general medical settings is largely uncharted terrain.
This is perhaps ironic given that the prescription of medications is the
one approach to addiction treatment that is most compatible with pri-
mary care practice.
One notable exception is a NIDA study testing the Advancing
Recovery implementation model to promote the increased use of
buprenorphine within a private health plan (NIH Reporter, 2015b). Ad-
vancing Recovery (Molfenter, McCarty, Capoccia, & Gustafson, 2014) is a
bundled implementation strategy that builds on the NIATx process im-
provement approach (Gustafson, Quanbeck, Robinson, Ford, et al.,
2013) to achieve widespread systems change. In addition to the use of
site-level change teams, coaching, and learning circles the core
components of NIATx Advancing Recovery attends to the relevant
nancing and policy levers by assisting organizations in building the
business case for integrating new practices. This type of approach to
implementation should maximize sustainability, by building organiza-
tional capacity to negotiate with key payers and to integrate new
approaches to treatment.
SUD QUERI investigators have three large projects approved to test
three different implementation strategies for expanding pharmacother-
apy for alcohol use disorder. The rst study is testing a multifaceted
intervention involving local champion training, ongoing external facili-
tation, a primary care-based case-nding dashboard, and direct to
 L.J. Ducharme et al. / Journal of Substance Abuse Treatment 60 (2016) 110118
patient educational materials (VHA, 2015c). The second project is eval-
uating an elaborated academic detailing program that was piloted in di-
verse clinical settings in 40 VHA facilities, including a real-time panel
management dashboard for case-nding and audit and feedback. A
third study is planned to evaluate a facilitation based implementation
of the primary care-coordinated Alcohol Care Management model
(Oslin et al., 2014). Once completed, these projects promise to provide
valuable information on the comparative effectiveness, moderators,
and costs of these varied implementation strategies. There is also sub-
stantial ongoing work to use Social Marketing Theory to identify market
segments within groups of primary care clinicians for which targeted
implementation strategies and messages might be developed to in-
crease consideration and use of these medications.
2.1.4. Safe opioid prescribing
A high priority area related to medications is the need to promote
safe prescribing of opiates for chronic non-cancer pain, including
avoiding high-dose opioid regimens and co-prescriptions with seda-
tives. Implementation studies in this area seek to change clinician pre-
scribing behavior in order to curb the epidemic of prescription drug
abuse and overdose risk. As such, this may be considered a form of
de-implementation research that is, identifying systematic strate-
gies to stop a current practice. In this case, studies use multifaceted
implementation strategies that are designed to sensitize physicians to
problematic opioid prescribing practices, facilitate information retrieval
to monitor high-risk patients, and support good clinical decision making.
Funded NIH studies in this area are similar to other clinical guideline
adherence studies, in that they are seeking to align routine practice with
consensus guidelines. As with analogous issues in other areas of
healthcare (e.g., handwashing (Huis et al., 2012)), implementation to
promote guideline adherence hinges on multifaceted strategies that in-
corporate education, reminders, feedback, and facilitative technology.
Current NIDA studies are testing two different approaches to promote
safe prescribing in primary care clinics. One focuses on surrounding pre-
scribing physicians with supports that should facilitate guideline-
adherent prescribing, combining education (academic detailing); a
nurse-managed patient registry to support monitoring of individual pa-
tients and clinic population outcomes; information systems that inte-
grate with the states prescription drug monitoring program database;
and point-of-care reminders. A second study combines physician- and
clinic-level implementation strategies, employing physician-targeted
education (peer coaching) and information system supports, while en-
gaging clinic leadership in a NIATx-based change team approach to re-
structure the clinic workow and procedures essentially engineering
an environment in which guideline adherence is the most likely outcome.
Much of the QUERI-supported work in this area has focused on
operationalizing clinical practice guidelines into metrics that have
been integrated into system monitoring and quality improvement
dashboards (e.g., VHA, 2015d). The portfolio also includes pre-
implementation work describing gaps in quality before and after the
initiation of a major Opioid Safety Initiative and understanding the
drivers of variability in quality (VHA, 2015e).
2.1.5. Disease management
It is well established that substance use is a key driver of health care
costs, and that patients with substance use disorders consume a dispro-
portionate share of emergency and urgent care services (Cherpitel & Ye,
2008; Neighbors et al., 2013; Walley et al., 2012). In the context of
health reform, identifying these patients and minimizing hospital
readmissions is a high priority goal (Billings & Mijanovich, 2007;
Pecoraro et al., 2012). Under the Affordable Care Act, healthcare pro-
viders positioning themselves as accountable care organizations or
patient-centered medical homes have strong incentives to identify
ways to increase patient engagement, improve monitoring, and follow
up with them more often. This policy change has renewed interest in
115
the application of the chronic care model (Wagner, Austin, & Von
Korff, 1996) to SUD treatment in primary care settings.
Chronic care management (CCM) is an approach to service delivery
that addresses coordination of patient care by a multidisciplinary team,
aided by clinical information systems; shared decision making;
restructuring of workow and practice design to facilitate coordinated
treatment; and decision support and clinical practice guidelines that re-
inforce the use of evidence-based practices. Together, these features are
intended to allow primary care physicians to identify, treat, and manage
the care of patients with chronic conditions.
While there is a strong evidence base for CCM generally (e.g., Tsai,
Morton, Mangione, & Keeler, 2005), and for its use in the care of diabetes
(Stellefson, Dipnarine, & Stopka, 2013), mental health (Woltmann et al.,
2012) and other chronic diseases in primary care settings, the evidence
for its impact on SUD outcomes, or on the increased delivery of SUD
treatments, has so far been mixed (Oslin et al., 2014; Park, Cheng,
Samet, Winter, & Saitz, 2015; Park et al., 2015). As a chronic condition,
it is reasonable to expect that SUD would realize similar benets from
CCM (Watkins, Pincus, Tanielian, & Lloyd, 2003). However, with few
exceptions (e.g., NIH Reporter, 2015c) our funded research to date has
not explicitly tested implementation strategies to install a chronic care
model for SUD. Rather, research on this topic is largely in the pre-
implementation stage that is to say, research is still testing the
effectiveness of key components of CCM for their impact on SUD service
delivery and outcomes. Ongoing research also includes important ob-
servational studies examining the impact of health reform on state-
level care coordination initiatives (e.g., NIH Reporter, 2015d, 2015e).
To be sure, CCM is an area in which the lines between effectiveness
and implementation research become blurred. As described above,
several studies are utilizing components of CCM as part of their imple-
mentation strategies to promote the uptake of other EBPs. For example,
a number of funded integration studies use patient registries to monitor
the service utilization and health status of patients receiving care from
the physicians, clinics, or hospitals in the implementation trials. These
registries often are designed to generate clinical alerts or reminders
for members of the care team; aggregate data can both provide a snap-
shot of service utilization and outcomes in the patient population, and
serve as performance feedback for clinicians.
In order for integration research to realize its potential, it is critical
that researchers accurately distinguish between health services effec-
tiveness studies i.e., those that test the impact of a service delivery
model on patient outcomes and implementation studies i.e., those
that test the impact of a particular strategy or bundle of strategies on
the delivery of evidence-based practices. Both are essential to achieving
integrated care for patients with SUD in primary care settings. Specic
to the chronic care model, it is important to not only identify which el-
ements are effective implementation strategies for EBPs, but also to bet-
ter specify the format, content, and contexts of organizational and
technical supports that might best facilitate coordinated SUD care. A
more mechanistic approach may be needed to determine which ele-
ments of CCM, in what combinations and contexts, are essential to sup-
port integrated SUD care. This can then provide the basis for strategic
implementation of more comprehensive models.
At the same time, CCM is also an area that may especially lend itself
to hybrid effectiveness-implementation study designs (Curran, Bauer,
Mittman, Pyne, & Stetler, 2012). Hybrid designs are becoming more
common in implementation science, and have the potential to
streamline the research-to-practice pipeline by incorporating both
effectiveness and implementation aims in the same study, whether in
equivalent or relative emphasis. For example, a study focused primarily
on testing the effectiveness of one or more CCM components could si-
multaneously collect data on feasibility, acceptability, or other elements
that inform its implementation (hybrid type 1). A study that tests an
implementation strategy to integrate CCM in a general medical setting
might also include secondary patient-level outcomes to check that the
processes are achieving their intended effects (hybrid type 3). Rather
116 L.J. Ducharme et al. / Journal of Substance Abuse Treatment 60 (2016) 110118
than pursue a typical (and time-consuming) linear research process
that moves to implementation only after effectiveness data have
reached a critical mass, the goals of service integration and implementa-
tion science can be accelerated by attending to both goals in the context
of the same study. While CCM might be the best current example of a
topic that is ripe for hybrid designs, much of the research in the area
of SUD service integration lends itself to this type of approach.
3. Discussion
Fitting within the theme of this special issue, we have focused our
analysis on ongoing efforts at NIH and the VHA to support implementa-
tion research targeting the integration of approaches to address SUD
and risky substance use in primary care and other general medical
settings. While these efforts are important, intriguing, and far from
nished, they are one part of a much larger effort that is needed to pro-
mote the identication and treatment of substance use disorder and
hazardous substance use across the full spectrum of medical settings
including mental health settings and HIV and other infectious disease
clinics that serve people at greatest risk for problematic substance use.
In addition, there remains a pressing need for implementation of
evidence-based practices in specialty SUD programs, including pharma-
cotherapies and smoking cessation interventions. Successful implemen-
tation research projects in general medical care may provide candidate
strategies that could be tested in these other settings.
Research funding agencies, providers, payers, patients, and advocacy
groups often prioritize patient-level outcomes demonstrating the effec-
tiveness of an intervention more than implementation outcomes. The
sometimes conicting priorities of healthcare administrators to achieve
measurable quality improvements, and of researchers to contribute to
implementation science, is a parallel challenge. Developing (and
powering) studies to simultaneously measure patient-level outcomes
while also determining implementation intervention effectiveness can
be expensive and may be impractical. Addressing this challenge calls
for exploration of alternative ways to capture patient-level outcomes
along with indicators of successful implementation. Hybrid designs (de-
scribed above) provide one approach to balancing these twin goals. At
the same time, technology that captures patient health status indicators
in the form of patient registries, electronic health records, claims data,
and other administrative data may help streamline the research process
such that patient-level outcomes can be more efciently measured. Of
course, prioritizing the integration of clinical interventions with a clear
evidence base strengthens assumptions that improvements in patient
outcomes will result from the receipt of integrated services.
Attending to clinical outcomes in the context of implementation re-
search is important not only to assess effectiveness and delity during a
given study, but also to understand whether and how interventions are
sustained and adapted over time to t the demands and constraints of
local service delivery settings. With only a few exceptions, our funded
projects largely fail to explicitly test hypotheses about the sustainability
of practices that have been implemented, or they view sustainment as a
discrete phase that happens only after an implementation phase or re-
search project. Rather, there is a need to understand how the interven-
tion development and implementation processes set the stage for
sustainment. Moreover, there is a need to understand the factors that
predict and foster sustainment of an adopted practice, particularly in
service delivery environments that themselves are constantly evolving
to meet changing internal and external demands. While the tendency
has been to view local adaptation as a failure to maintain delity, it
may instead be the case that local adaptation is necessary to ensure
the continued t of the practice to its delivery context (Chambers
et al., 2013). Where practical, collecting patient-level outcome data is
important for understanding whether local adaptation degrades the
quality of care, or is in fact a benecial optimization of the intervention.
In addition to strategically incorporating patient clinical outcomes in
implementation research, it is also important to recognize that patient
voice is often absent from substance use care, the research literature,
and the development of novel interventions. Yet patient preference is
a critical component of intervention uptake and sustainability. With
few exceptions (e.g., NIH Reporter, 2015f), our portfolios have included
few projects with an explicit focus on shared decision-making between
patients, their families, and their healthcare providers. More such re-
search is needed to inform treatment developers about the features
that would make SUD care attractive, accessible, and meaningful within
the context of patients lives. The eld could also benet from develop-
ing and testing more direct-to-consumer dissemination activities, and
demand-side implementation intended to build consumer calls for
evidence-based interventions. This information could be collected as
part of a larger implementation research study examining issues related
to taking to scale patient-centered care for substance use.
Despite the fact that the onset and peak of substance use occurs in
adolescence, most of the research on developing medications, psycho-
social interventions, and models of care has focused on adult popula-
tions. Likewise, much of the NIH-funded SUD implementation
research to date focuses on integrating evidence-based interventions
within settings serving adults. There seems to be an assumption that
this accumulating knowledge base will directly apply and translate to
adolescent treatment settings. However, we know little about the
unique challenges faced by healthcare providers, organizations, and sys-
tems seeking to address substance use among their adolescent and
young adult patients. It is plausible that these general medical settings
will need to surmount additional and unique implementation challenges,
including the involvement of patients families. Research gaps in this
area are extensive and could be addressed with pre-implementation
studies to determine organizational and systems level barriers to en-
gaging adolescents and their families in treatment, and implementing
evidence-based interventions. Implementation research studies could
translate this knowledge into unique strategies for fostering uptake of
evidence-based prevention and treatment services for substance use,
including technology-driven interventions that may be appealing
to adolescents.
Finally, outside of the relatively small circle of health services re-
searchers, implementation research is often poorly understood and
therefore undervalued. Improving this situation requires the consistent
application of rigorous scientic standards including the development
and application of conceptual frameworks; identication of interven-
tion targets; clearly specied implementation strategies; addressing
the competing pressures for adaptation and delity in delivering inter-
ventions; and well dened outcomes with appropriate measures. Use of
common measures, conceptual models, and denitions will allow for
the integration and comparison of data across studies, and must be a
near-term goal for implementation science. By the same token, we rec-
ognize that implementation research may also benet from greater co-
ordination and cross-fertilization of SUD implementation research
between NIH and VHA. For example, research should seek to test
whether implementation strategies determined to be effective in inte-
grating care in the VHA are equally effective in other sectors, and vice
versa. As VHA becomes more of a payer as well as a provider of health
care under the Veterans Choice Act, there will be more opportunities
and motivations for studying cross-system coordination and compari-
sons of implementation contexts.
Unprecedented change in healthcare policy, funding, and technolo-
gy provide the potential to expand the identication, treatment, and on-
going care management of substance using patients wherever they seek
medical care. Within this larger context, implementation science pro-
vides an opportunity to develop a knowledge base to promote the sys-
tematic adoption of evidence-based approaches to substance use
treatment in a variety of healthcare and general medical settings.
NIAAA, NIDA, and VHA have built portfolios that are leading the addic-
tion health services research eld in this area. This research could be
pivotal in reducing the public health burden of substance use across
the United States.
 L.J. Ducharme et al. / Journal of Substance Abuse Treatment 60 (2016) 110118
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